| NPI | 1023590502 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: CT 004247) |
| Enumeration Date | 2018-08-31 |
| Last Update Date | 2022-09-15 |